ATI RN
ATI Detailed Answer Key Medical Surgical Questions
Question 1 of 5
While providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?
Correct Answer: B
Rationale: The correct answer is B because facilitating the client's deep breathing is crucial post-CABG surgery to prevent complications such as atelectasis and pneumonia. Deep breathing helps improve lung expansion and oxygenation, promoting healing and preventing respiratory issues. A: While decreasing anxiety is important for overall well-being, it is not directly related to the client's recovery post-CABG surgery. C: Enhancing sleep is beneficial for healing, but it is not as critical as ensuring proper respiratory function in the immediate postoperative period. D: While reducing blood pressure may be desirable in some cases, it is not the most important effect to focus on post-CABG surgery; maintaining adequate oxygenation through deep breathing takes precedence.
Question 2 of 5
A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Administer oxygen via nasal cannula. In a client with a sucking chest wound, the priority is to ensure adequate oxygenation due to potential respiratory compromise. Administering oxygen via nasal cannula will help improve oxygenation and support the client's respiratory function. This action takes precedence over other interventions as hypoxia can lead to further deterioration. A: Raising the foot of the bed to a 90° angle is not indicated in this situation as it does not address the immediate need for oxygenation. B: Removing the dressing to inspect the wound can worsen the condition by disrupting any seals in place to prevent air from entering the chest cavity. C: Preparing to insert a central line is not the priority in this situation as the client's respiratory status needs to be stabilized first.
Question 3 of 5
While suctioning the endotracheal tube of a client on a ventilator, the nurse notices an increase in the client's heart rate from 86/min to 110/min, with irregularity. What should the nurse do next?
Correct Answer: D
Rationale: The correct answer is D: Perform pre-oxygenation prior to suctioning. In this scenario, the increase in heart rate and irregularity could be due to hypoxia resulting from suctioning. Pre-oxygenation helps to ensure adequate oxygenation before the procedure, preventing hypoxia-induced dysrhythmias. By providing oxygen before suctioning, the nurse can minimize the risk of further complications. Choice A (Obtain a cardiology consult) is incorrect because immediate action is required to address the potential hypoxia, which can be managed by pre-oxygenation. Choice B (Suction the client less frequently) is incorrect as it does not address the immediate concern of potential hypoxia leading to dysrhythmias. Choice C (Administer an antidysrhythmic medication) is incorrect as it is not the initial intervention needed in this situation; addressing the underlying cause of potential hypoxia is essential before considering antidysrhythmic medications.
Question 4 of 5
A post-anesthesia care unit nurse is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give the highest priority to?
Correct Answer: A
Rationale: The correct answer is A: Arterial blood gases. This is the highest priority assessment for a client post-thoracotomy and lobectomy as it helps monitor the client's oxygenation status and acid-base balance, crucial after thoracic surgery. ABGs provide immediate information on the client's respiratory function, detecting any respiratory complications early on. The other options, B: Urinary output, C: Chest tube drainage, and D: Pain level, are important assessments but not as critical as monitoring the client's oxygenation status post-thoracic surgery. Urinary output is important for renal function, chest tube drainage for monitoring for any bleeding or air leakage, and pain level for comfort, but none of these directly assess the client's respiratory status and potential complications.
Question 5 of 5
A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?
Correct Answer: D
Rationale: Step 1: The client with gastroenteritis is at risk for fluid volume deficit due to vomiting and diarrhea, leading to loss of fluids. Step 2: Febrile state increases fluid loss through sweating. Step 3: Combining gastroenteritis and fever exacerbates fluid loss, making this client at high risk. Step 4: Clients A, B, and C do not have immediate factors contributing to fluid volume deficit as evident from their conditions. Summary: Client D is at risk due to gastroenteritis and fever causing significant fluid loss. Clients A, B, and C do not have conditions directly leading to fluid deficit.